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208Mid-Term: Continuing to Fly .................................................................................................................... 208Long-Term: Future Directions for the U.S. in Space ................................................................................. 209Chapter 1010.110.210.310.410.510.610.710.810.910.1010.1110.12Other Significant ObservationsPublic Safety ..............................................................................................................................................Crew Escape and Survival .........................................................................................................................Shuttle Engineering Drawings and Closeout Photographs ........................................................................Industrial Safety and Quality Assurance ....................................................................................................Maintenance Documentation .....................................................................................................................Orbiter Maintenance Down Period/Orbiter Major Modification ...............................................................Orbiter Corrosion .......................................................................................................................................Brittle Fracture of A-286 Bolts ..................................................................................................................Hold-Down Post Cable Anomaly ..............................................................................................................Solid Rocket Booster External Tank Attachment Ring .............................................................................Test Equipment Upgrades ..........................................................................................................................Leadership/Managerial Training ................................................................................................................Chapter 11Recommendations ...................................................................................................................................

225PART FOURAPPENDICESAppendix AThe Investigation ..................................................................................................................................... 231Appendix BBoard Member Biographies ..................................................................................................................239Appendix CBoard Staff .............................................................................................................................................. 243VOLUME IIAppendix DCAIB Technical Documents Cited in the ReportVOLUME IIIAppendix EOther Technical Documents Cited in the ReportVOLUME IVAppendix FOther Technical DocumentsVOLUME VAppendix GOther Significant DocumentsVOLUME VIAppendix HTranscripts of Board Public HearingsReport Volume IAugust 20031951961971991992022132142172172202202212222222232232235COLUMBIAACCIDENT INVESTIGATION BOARDBOARD STATEMENTFor all those who are inspired by flight, and for the nationwhere powered flight was first achieved, the year 2003 hadlong been anticipated as one of celebration – December 17would mark the centennial of the day the Wright Flyer firsttook to the air.

But 2003 began instead on a note of suddenand profound loss. On February 1, Space Shuttle Columbiawas destroyed in a disaster that claimed the lives of all sevenof its crew.While February 1 was an occasion for mourning, the effortsthat ensued can be a source of national pride. NASA publiclyand forthrightly informed the nation about the accident andall the associated information that became available.

The Columbia Accident Investigation Board was established withintwo hours of the loss of signal from the returning spacecraftin accordance with procedures established by NASA following the Challenger accident 17 years earlier.The crew members lost that morning were explorers in thefinest tradition, and since then, everyone associated with theBoard has felt that we were laboring in their legacy. Ours, too,was a journey of discovery: We sought to discover the conditions that produced this tragic outcome and to share thoselessons in such a way that this nationʼs space program willemerge stronger and more sure-footed.

If those lessons aretruly learned, then Columbiaʼs crew will have made an indelible contribution to the endeavor each one valued so greatly.After nearly seven months of investigation, the Board hasbeen able to arrive at findings and recommendations aimedat significantly reducing the chances of further accidents.Our aim has been to improve Shuttle safety by multiplemeans, not just by correcting the specific faults that costthe nation this Orbiter and this crew. With that intent, theBoard conducted not only an investigation of what happenedto Columbia, but also – to determine the conditions that allowed the accident to occur – a safety evaluation of the entire Space Shuttle Program.

Most of the Boardʼs efforts wereundertaken in a completely open manner. By necessity, thesafety evaluation was conducted partially out of the publicview, since it included frank, off-the-record statements bya substantial number of people connected with the Shuttleprogram.In order to understand the findings and recommendations inthis report, it is important to appreciate the way the Boardlooked at this accident. It is our view that complex systemsalmost always fail in complex ways, and we believe it wouldbe wrong to reduce the complexities and weaknesses associated with these systems to some simple explanation.

Toooften, accident investigations blame a failure only on thelast step in a complex process, when a more comprehensiveunderstanding of that process could reveal that earlier stepsmight be equally or even more culpable. In this Boardʼsopinion, unless the technical, organizational, and culturalrecommendations made in this report are implemented, littlewill have been accomplished to lessen the chance that another accident will follow.6Report Volume IFrom its inception, the Board has considered itself an independent and public institution, accountable to the Americanpublic, the White House, Congress, the astronaut corps andtheir families, and NASA. With the support of these constituents, the Board resolved to broaden the scope of the accidentinvestigation into a far-reaching examination of NASAʼsoperation of the Shuttle fleet. We have explored the impactof NASAʼs organizational history and practices on Shuttlesafety, as well as the roles of public expectations and nationalpolicy-making.In this process, the Board identified a number of pertinentfactors, which we have grouped into three distinct categories:1) physical failures that led directly to Columbiaʼs destruction; 2) underlying weaknesses, revealed in NASAʼs organization and history, that can pave the way to catastrophicfailure; and 3) “other significant observations” made duringthe course of the investigation, but which may be unrelatedto the accident at hand.

Left uncorrected, any of these factorscould contribute to future Shuttle losses.To establish the credibility of its findings and recommendations, the Board grounded its examinations in rigorous scientific and engineering principles. We have consulted withleading authorities not only in mechanical systems, but alsoin organizational theory and practice. These authoritiesʼ areasof expertise included risk management, safety engineering,and a review of “best business practices” employed by otherhigh-risk, but apparently reliable enterprises. Among theseare nuclear power plants, petrochemical facilities, nuclearweapons production, nuclear submarine operations, and expendable space launch systems.NASA is a federal agency like no other.